Intravitreal bevacizumab treatment of radiation maculopathy due to brachytherapy in choroidal melanoma

Hypoxia-dependent drivers of melanoma progression

Hypoxia, a condition of low oxygen availability, is a hallmark of tumour microenvironment and promotes cancer progression and resistance to therapy. Many studies reported the essential role of hypoxia in regulating invasiveness, angiogenesis, vasculogenic mimicry and response to therapy in melanoma. Melanoma is an aggressive cancer originating from melanocytes located in the skin (cutaneous melanoma), in the uveal tract of the eye (uveal melanoma) or in mucosal membranes (mucosal melanoma). These three subtypes of melanoma represent distinct neoplasms in terms of biology, epidemiology, aetiology, molecular profile and clinical features.In this review, the latest progress in hypoxia-regulated pathways involved in the development and progression of all melanoma subtypes were discussed. We also summarized current knowledge on preclinical studies with drugs targeting Hypoxia-Inducible Factor-1, angiogenesis or vasculogenic mimicry. Finally, we described available evidence on clinical studies investigating the use of Hypoxia-Inducible Factor-1 inhibitors or antiangiogenic drugs, alone or in combination with other strategies, in metastatic and adjuvant settings of cutaneous, uveal and mucosal melanoma.Hypoxia-Inducible Factor-independent pathways have been also reported to regulate melanoma progression, but this issue is beyond the scope of this review.As evident from the numerous studies discussed in this review, the increasing knowledge of hypoxia-regulated pathways in melanoma progression and the promising results obtained from novel antiangiogenic therapies, could offer new perspectives in clinical practice in order to improve survival outcomes of melanoma patients.

Antiangiogenic or Corticosteroid Treatment in Patients With Radiation Maculopathy After Proton Beam Therapy for Uveal Melanoma

PURPOSE

To reveal differences or advantages in regard to different treatment options after proton beam therapy for uveal melanoma.

DESIGN

Retrospective, comparative, interventional case series.

METHODS

All patients receiving intravitreal treatment between January 2011 and July 2014 for radiation maculopathy after proton beam therapy were included. Excluded were all patients who required re-irradiation, vitrectomies, or tumor resections; and those whose treatment was performed for potentially other reasons, such as radiation-induced optic neuropathy, or where visual outcome was influenced by tumor growth under the macula or macular ischemia. Minimum follow-up was 12 months after last injection.

RESULTS

Of 78 patients, 38 (48.7%) received bevacizumab injections, 35 (44.9%) triamcinolone acetonide injections, and 5 (6.4%) a dexamethasone implant. In the bevacizumab group visual acuity improved in 11 patients (28.9%) by 0.25 logMAR (0.1-0.4 logMAR) and remained stable in 24 patients (63.2%) 4 weeks after injection. In the triamcinolone group visual acuity showed improved outcomes in 10 patients (28.6%) by 0.25 logMAR (0.1-0.4 logMAR) and stability in function in 20 patients (57.1%). Four weeks after dexamethasone implantation visual acuity remained stable in 4 patients (80%). No differences among the groups were detected regarding functional outcome or reduction in central foveal thickness.

CONCLUSIONS

This study showed that antiangiogenic or corticosteroid intravitreal treatment led to reduced central foveal thickness and visual improvement in some patients without showing differences or advantages. Therefore a patient-specific treatment choice can be recommended.

Anti-VEGF intravitreal bevacizumab for radiation-associated neovascular glaucoma

BACKGROUND AND OBJECTIVE

To report outcomes of intravitreal bevacizumab therapy in radiation-associated neovascular glaucoma (NVG).

PATIENTS AND METHODS

In this retrospective interventional case series, 12 eyes with NVG after radiation therapy for ocular malignancy were treated with periodic intravitreal injections of 1.25 mg bevacizumab. Outcome measures included changes in iris neovascularization, intraocular pressure (IOP), visual acuity, and pain.

RESULTS

One month after the first injection, iris neovascularization regressed in nine of 12 eyes (75%), and IOP decreased in eight of 12 eyes (67%) by a mean of 10.1 mm Hg. Patients were monitored for a mean of 26.5 months after their first injection. Six eyes subsequently underwent enucleation for pain control (four eyes; 66%), chronic uveitis (one eye; 17%), and tumor recurrence (one eye; 17%). All remaining patients experienced deterioration in visual acuity (range: 20/160 to no light perception), but pain control was good and IOP normalized in four patients.

CONCLUSION

Intravitreal bevacizumab therapy should be considered for patients with radiation-associated NVG who wish to avoid enucleation.

Intravitreal anti-VEGF therapy for macular radiation retinopathy: a 10-year study

PURPOSE

To report long-term experience with intravitreal anti-vascular endothelial growth factor treatment for radiation maculopathy.

METHODS

From 2005-2015, 120 consecutive patients underwent intravitreal anti-VEGF therapy for radiation maculopathy. Inclusion criteria included a diagnosis of uveal melanoma treated with plaque radiotherapy and subsequent macular radiation vasculopathy (exudate, retinal hemorrhage, intraretinal microangiopathy, neovascularization, edema). Anti-VEGF therapy involved continuous injections in 4- to 12-week intervals with doses of 1.25 mg/0.05 mL, 2.0 mg/0.08 mL, 2.5 mg/0.1 mL, or 3.0 mg/0.12 mL of bevacizumab as well as 0.5 mg/0.05 mL or 2.0 mg/0.05 mL of ranibizumab. Goals were maintenance of visual acuity and normative macular anatomy. Safety and tolerability (retinal detachment, hemorrhage, infection), visual acuity, central foveal thickness on optical coherence tomography imaging, and clinical features of radiation maculopathy were analyzed.

RESULTS

Progressive reductions in macular edema, hemorrhages, exudates, cotton-wool spots, and microangiopathy were noted. At last follow-up, 80% remained within 2 lines of their initial visual acuity or better, with a mean treatment interval of 38 months (range 6-108 months). Kaplan-Meier analysis of the probability of remaining within 2 lines of initial visual acuity was 69% at 5 years and 38% at 8 years of anti-VEGF therapy. Discontinuation of therapy was rare. Relatively few acute or long-term side effects were noted, allowing for good long-term patient accrual.

CONCLUSIONS

Continuous intravitreal anti-VEGF therapy in patients with radiation maculopathy was well-tolerated and preserved vision. In most cases, reductions or resolution of retinal hemorrhages, cotton-wool spots, and retinal edema were noted for up to 10 years.

New treatments in radiation retinopathy

PURPOSE

The purpose of this study was to present a case of radiation retinopathy and review of the literature on treatment options for the disease.

METHODS

A 28-year-old woman presented with bilateral visual acuity impairment. Four years before presentation, she was diagnosed with Hodgkin lymphoma affecting the left supraclavicular area and was treated with chemotherapy and radiotherapy, achieving complete remission. Bilateral radiation retinopathy with macular edema was diagnosed after the possibility of relapse was ruled out. Several treatments, including intravitreal bevacizumab and triamcinolone, laser photocoagulation, and surgery, have been used in an effort to resolve the macular edema and the tractional proliferative retinopathy.

RESULT

Radiation tractional retinopathy was controlled with surgery and photocoagulation, and macular edema was resolved with a final visual acuity of 20/25 in both eyes.

CONCLUSION

Radiation retinopathy is a complication that is devastating to the visual pathway. Historically, it has been refractory to treatment, but new options are now available. We review the most recent literature on radiation retinopathy treatment.

Current treatments for radiation retinopathy

BACKGROUND

to review the currently available therapeutic modalities for radiation retinopathy (RR), including newer investigational interventions directed towards specific aspects of the pathophysiology of this refractory complication.

METHODS

a review of the literature encompassing the pathogenesis of RR and the current therapeutic modalities available was performed.

RESULTS

RR is a chronic and progressive condition that results from exposure to any source of radiation. It might be secondary to radiation treatment of intraocular tumors such as choroidal melanomas, retinoblastomas, and choroidal metastasis, or from unavoidable exposure to excessive radiation from the treatment of extraocular tumors like cephalic, nasopharyngeal, orbital, and paranasal malignancies. After the results of the Collaborative Ocular Melanoma Study, most of the choroidal melanomas are being treated with plaque brachytherapy increasing by that the incidence of this radiation complication. RR has been reported to occur in as many as 60% of eyes treated with plaque radiation, with higher rates associated with larger tumors. Initially, the condition manifests as a radiation vasculopathy clinically seen as microaneurysms and telangiectases, with posterior development of retinal hard exudates and hemorrhages, macular edema, neovascularization and tractional retinal detachment. Regrettably, the management of these eyes remains limited. Photodynamic therapy, laser photocoagulation, oral pentoxyphylline and hyperbaric oxygen have been attempted as treatment modalities with inconclusive results. Intravitreal injections of anti-vascular endothelial growth factor such as bevacizumab, ranibizumab and pegaptanib sodium have been recently used, also with variable results.

DISCUSSION

RR is a common vision threatening complication following radiation therapy. The available therapeutic options are limited and show unsatisfactory results. Further large investigative studies are required for developing better therapeutic as well as preventive treatment strategies.

Resolution of macular edema in radiation retinopathy after intravenous diuresis

PURPOSE

To report resolution of bilateral macular edema secondary to radiation retinopathy after intravenous diuresis.

METHODS

Observational case report, consisting of clinical examination, fluorescein angiography, and optical coherence tomography.

RESULTS

A 38-year-old woman developed radiation retinopathy and severe macular edema secondary to whole brain radiation therapy for metastatic breast cancer. After diuresis with intravenous furosemide for pleural effusion, the bilateral macular edema resolved.

CONCLUSION

In select patients, systemic diuresis may aid in resolving macular edema.

Bevacizumab (Avastin) for the treatment of ocular disease

The use of intravitreal bevacizumab (Avastin) has greatly expanded since its introduction into ophthalmic care 3 years ago. A PubMed search on 1 August 2008 revealed 51 ocular disease processes that have been treated with bevacizumab. The majority of publications consist of case reports or retrospective case series and their number is increasing quickly. It is important to collate the experiences gained to date to properly inform our clinical decision making and improve the design of future clinical trials. Current studies cannot easily be combined in a meta-analysis given the lack of standardized data and the wide variety of disorders studied in small numbers. This paper will describe the attempted uses of intravitreal bevacizumab and its efficacy for each ocular disease in addition to discussing safety. Comments regarding appropriate use of this treatment are based on our current level of knowledge. It is clear that the initial encouraging results described in this paper warrant further study of intravitreal bevacizumab in larger, controlled, randomized trials.

Periocular triamcinolone for prevention of macular edema after plaque radiotherapy of uveal melanoma: a randomized controlled trial

OBJECTIVE

To determine the efficacy and safety of periocular triamcinolone acetonide (40 mg) for the prevention of macular edema in patients undergoing plaque radiotherapy for uveal melanoma.

DESIGN

Prospective, randomized, controlled clinical trial.

PARTICIPANTS AND CONTROLS

One-hundred sixty-three patients with newly diagnosed uveal melanoma undergoing iodine 125 plaque radiotherapy were entered into the study. Fifty-five patients were randomized to the control group and 108 to the triamcinolone group. Eighteen-month data were available for 143 (88%) of the 163 patients.

INTERVENTION

Periocular injection of triamcinolone acetonide (40 mg in 1 ml) at the time of plaque radiotherapy and 4 months and 8 months later. Optical coherence tomography was performed at each patient evaluation.

MAIN OUTCOME MEASURES

Optical coherence tomography-evident macular edema, moderate vision loss, and poor final visual acuity.

RESULTS

Optical coherence tomography-evident macular edema occurred significantly less often in the triamcinolone group compared with the control group up to 18 months after plaque radiotherapy (hazard estimate, 0.45; 95% confidence interval, 0.19-0.70; P = 0.001). At the 18-month follow-up, moderate vision loss (loss of 3 lines or more of best-corrected visual acuity [BCVA]) and severe vision loss (BCVA <5/200 Snellen) occurred significantly less frequently in the triamcinolone group than in the control group (31% vs. 48% [P = 0.039] and 5% vs. 15% [P = 0.048], respectively). Rates of elevated intraocular pressure and cataract progression were similar in both groups.

CONCLUSIONS

Periocular triamcinolone is beneficial in reducing the risk of macular edema up to 18 months after plaque radiotherapy for uveal melanoma and significantly reduces the risk of moderate vision loss and poor visual acuity in these patients.

Assessment of central vision and macular structure in patients undergoing iodine-125 brachytherapy for ciliochoroidal melanoma

OBJECTIVES

To prospectively report standardized visual function and macular structural assessment in patients undergoing iodine-125 brachytherapy for choroidal and ciliary body melanoma.

MATERIALS AND METHODS

Patients were enrolled for pretreatment and annual posttreatment assessment. Evaluations included ophthalmic history; standardized refraction; visual acuity, contrast sensitivity, and color vision measurement; comprehensive ophthalmic examination; fundus photography; fluorescein angiography; optical coherence tomography; and ultrasonography. Radiation doses to the foveola and optic disc margin were calculated.

RESULTS

Forty-two patients were enrolled. Melanoma location included 3 in the ciliary body, 7 anterior, 11 equatorial, 13 posterior, and 8 macular tumors. Mean apical tumor height was 4.45 mm (range 1.79-9.83 mm) and mean longitudinal tumor diameter was 9.41 mm (range 4.52-4.73 mm). Pretreatment mean best-corrected Ferris-Bailey early treatment diabetic retinopathy study visual acuity was 50 (standard deviation +/- 15) letters (Snellen equivalent 20/32, range 20/15 to hand motions). The mean Pelli-Robson contrast threshold percentage was 4.1% (+/- 2.5%). The mean Hardy-Rand-Rittler color vision score was 13/14 (+/- 2.7). Mean distances from the posterior edge of the tumor to the foveola and the optic disc margin were 6.99 mm (+/- 6.22 mm) and 7.28 mm (+/- 5.98 mm), respectively. At the foveola, median total radiation dose was 36.2 Gy (+/-50.6 Gy) and median dose rate was 31.6 cGy/h (+/- 39.8 cGy/h). At the optic nerve, median total radiation dose was 42.8 Gy (+/- 30.8 Gy) and median dose rate was 36.2 cGy/h (+/- 21.4 cGy/h).

CONCLUSION

This prospective assessment of macular structure and function will provide more complete understanding of the ocular effects of radiation therapy for ocular melanoma.

Regression of radiation-induced macular edema after systemic bevacizumab

CASE REPORT

A 59-year-old patient with a coexisting primary choroidal melanoma and colorectal cancer was treated with external beam radiation (EBR) of his choroidal melanoma and systemic chemotherapy with leukovorin/5 fluorouracil (FU) for treatment of his metastatic colorectal cancer. Eight months following EBR, he showed evidence of radiation retinopathy with macular edema. Optical coherence tomography (OCT) showed macular edema and subretinal fluid. Subsequently, systemic bevacizumab (5 mg/kg) was added to his leukovorin/5FU chemotherapy. After the addition of bevacizumab, OCT showed complete resolution of the macular edema and subretinal fluid.

COMMENTS

Bevacizumab may have a role in the treatment of radiation retinopathy, but further investigation is needed before any definitive conclusions can be made.